DISTRIBUTION CHANNEL INFORMATION AGENT/ BROKER CODE: _________________________ MYMAXICARE APPLICATION FORM APPLICANT'S INFORMATION NOTE: TO FACILITATE PROCESSING OF THIS APPLICATION, PLEASE ACCOMPLISH THIS FORM IN FULL. KINDLY WRITE IN BLOCK LETTERS AND CHECK THE APPROPRIATE BOX WHERE APPLICABLE NEW APPLICANT ADDITIONAL APPLICANT REAPPLICATION TRANSFEREE Type of Coverage Plan Type Mode of Payment Dental Coverage Philhealth Member Individual Platinum Plus Annual Yes Yes Family Platinum Semi-Annual No No Group/Corporate Gold Quarterly Silver Specify Name: ___________________ PAYMENT OPTION CREDIT CARD OVER-THE-COUNTER BANK MAXICARE OFFICE CASHIER PERSONAL INFORMATION (PRINCIPAL/ PAYOR) LAST NAME CIVIL STATUS NO. OF CHILDREN RESIDENCE ADDRESS (NO., STREET, VILLAGE, BRGY., TOWN/MUNICIPALITY, PROVINCE, ZIP CODE) CONTACT PERSON & MAILING ADDRESS (NUMBER, STREET, VILLAGE, BRGY, CITY, ZIP CODE)(IF UNDER AN AGENT/BROKER PLEASE INDICATE AGENTS/BROKERS ADDRESS) FIRST NAME GENDER JOB TITLE MIDDLE NAME EMAIL ADDRESS NAME OF OFFICE/BUSINESS EXTENSION NAME (JR, SR,III) DATE OF BIRTH (MM/DD/YYY) HOME NUMBER BLOOD PRESSURE (mmHg) NATIONALITY SSS/GSIS//PHILHEALTH (If available) Encircle the appropriate institution that issued the ID number AGE MOBILE NUMBER HEIGHT (FT.iN) OFFICE PHONE NO. WEIGHT (LBS) OFW ID NUMBER: TAX IDENTIFICATION NUMBER (TIN) (if available) PERSONAL INFORMATION (DEPENDENT/S) 1 2 3 4 5 if Applying FULL NAME OF APPLICANT RELATION AGE GENDER DATE OF BIRTH (MM/DD/YYY) CIVIL STATUS HEIGHT WEIGHT BLOOD PRESSURE PHILHEALTH MEMBER? (Y/N) DENTAL COVERAGE (Y/N) OCCUPATION DEPENDENTS PLAN TYPE Platinum Plus Platinum Gold Silver FOR FAMILY AND GROUP ACCOUNTS: 15 DAYS OLD UP TO 21 YEARS AND 5 MONTHS OLD ARE ACCEPTABLE AGES FOR MINOR DEPENDENTS. CHILDREN WHO ARE 22 YEARS OLD AND ABOVE WILL BE CONSIDERED AS INDIVIDUAL APPLICANTS. BENEFICIARIES (Note: Standard beneficiaries are immediate family members) 1 2 3 4 5 check the box on the left side if the beneficiaries is same as above dependents. Please make sure to choose correct corresponding numbers Name Relationship to Principal Birthday Age STATEMENT OF DETAILS I/We hereby clearly understand and agree that failure to declare illnesses in the following questions (referring to any proposed member) will invalidate future claims and that the corresponding details of which will be indicated in Statement of Details. MEDICAL QUESTIONNAIRE 1. Has any proposed member/s complained of any untoward symptoms pertaining to diseases or conditions of: 1a. The brain or nervous system – such as loss of consciousness, dizziness, headaches, seizure disorder, paralysis, mental retardation, stroke? 1b. The cardiovascular system – such as heart disease, rheumatic fever, palpitation, shortness of breath, chest pain, high or abnormal blood pressure, heart murmur, etc.? 1c. The peripheral vascular diseases – such as varicose veins, phlebitis, aneurysm, arthritis, embolism, etc.? 1d. The digestive system – such as ulcer, gall bladder disorder, liver disease, colitis, chronic diarrhea, fistula, hemorrhoids, colon or intestinal disorder, hernia, malabsorption and pancreatitis? 1e. The genito-urinary system – such as renal colic, stone, bladder or kidney disorder, stricture, prostate disorder, syphilis, or venereal disease, etc.? 1f. The metabolic system – such as diabetes, gout, thyroid or adrenal disorder etc. and immune system disorders including acquired immune deficiency syndrome (AIDS), AIDS-related complex (ARC) etc.? 1g. The musculo-skeletal system – such as back sprain, neck or back disorder arthritis, fractures, slipped disc, dislocation, joint problems, physically handicapped, etc.? 1h. The respiratory tract – such as asthma, tuberculosis, spitting or coughing blood, allergies, emphysema, lung/chest disease of any kind, etc.? 2. Has any proposed member/s ever received a medical advice or treatment for, or ever had any known indications of any breast condition, infertility or other female problems? 3. So far as you know, is a proposed member/s now pregnant? Expected delivery date: (mm-dd-yyyy) __________________________ 3a. If YES, is caesarean section anticipated? 4. Has any proposed member/s ever received medical advice or treatment for: 4a. Disease of eyes, ears, nose or throat? 4b. Any skin disorders, cancer, psoriasis, keratosis, herpes, etc.? 4c. Cancer? 4d. Tumor? 4e. Alcoholism or drug dependency? 4f. If YES to 4e, is he a member of a support group? 5. Has any proposed member/s ever had any: 5a. Hospitalization/Surgery? If YES, please give details ____________________________________________________________________________________________ 6. Any congenital disorders? YES NO Form Template Control: Underwriting and Enrollment Fulfilment/ August 7, 2017 /FO-UEF-0.027/Rev.01